A nurse is assisting with the care of a preschooler who is immediately postoperative following a tonsillectomy. Which of the following actions should the nurse take?
Apply an ice collar.
Encourage the child to use a straw.
Remind the child to cough and deep breathe.
Provide cherry fruit juice.
The Correct Answer is A
A. Applying an ice collar helps reduce swelling and discomfort in the throat after a tonsillectomy. Cold therapy is effective in the early postoperative period to minimize bleeding and pain.
B. Using a straw should be avoided after a tonsillectomy because it may cause trauma to the surgical site and increase the risk of bleeding.
C. Coughing and deep breathing should be avoided after a tonsillectomy as they can cause irritation or dislodge the blood clots in the surgical site, leading to bleeding.
D. Providing cherry fruit juice is not ideal, as acidic or red-colored liquids can irritate the throat and may make it difficult to monitor for post-operative bleeding.
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Related Questions
Correct Answer is C
Explanation
A. Selecting a catheter that fits snugly is important for proper suctioning, but it is more important to ensure the catheter is the correct size for the infant’s tracheostomy tube and airway.
B. Instilling saline prior to suctioning is generally not recommended unless specified by the healthcare provider, as it can increase the risk of aspiration and discomfort.
C. Suctioning should be done in short 3 to 4 second increments to avoid injury to the airway and to minimize the infant’s distress. Prolonged suctioning can cause hypoxia and trauma to the mucosa.
D. Suctioning for infants with tracheostomies requires sterile technique to prevent infection, not clean technique.
Correct Answer is D
Explanation
A. Increased blood pressure is typically not associated with dehydration. In fact, dehydration often causes hypotension or low blood pressure, especially in severe cases.
B. Distended jugular veins are usually a sign of fluid overload or heart failure, not dehydration. In dehydration, the veins may appear flat due to decreased fluid volume.
C. A flat anterior fontanel is generally expected in a well-hydrated child. A sunken fontanel would indicate dehydration in infants and young toddlers.
D. Increased pulse (tachycardia) is a common sign of dehydration. As the body loses fluid, the heart compensates by increasing the heart rate to maintain adequate perfusion of organs.
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